A client has a sodium level of 121 mEq/L. What is the priority nursing intervention?

Place the client on seizure precautions

Educate on foods high in sodium

Administer a bolus of sodium chloride 3%

Place on a 1-liter-per-day fluid restriction

Answer and Explanation

The Correct Answer is A

Choice A reason: A sodium level of 121 mEq/L indicates severe hyponatremia, risking seizures due to cerebral edema from low osmolality. Seizure precautions (e.g., padded rails, anticonvulsants) protect from injury during potential seizures, making this the priority to ensure safety before correcting sodium levels.

Choice B reason: Educating on high-sodium foods is a long-term strategy for hyponatremia but not the priority. Severe hyponatremia (121 mEq/L) risks seizures, requiring immediate protective measures like seizure precautions over dietary education, which addresses chronic management rather than acute neurological risks.

Choice C reason: Administering 3% sodium chloride corrects hyponatremia but is not the first priority. Rapid correction risks osmotic demyelination, and seizure precautions are needed to protect against cerebral edema-induced seizures, a more immediate risk in severe hyponatremia, before initiating sodium therapy.

Choice D reason: A 1-liter-per-day fluid restriction addresses fluid overload in hyponatremia but is secondary to seizure precautions. Severe hyponatremia (121 mEq/L) risks neurological complications like seizures, making immediate safety measures the priority over fluid restriction, which is a slower corrective strategy.

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Correct Answer is B

Explanation

Choice A reason: A basic metabolic panel assesses electrolytes and renal function but does not identify the bacterial cause of pneumonia. It supports overall patient status but does not guide antibiotic selection, making it less critical than sputum culture for ensuring targeted, effective antibiotic therapy.

Choice B reason: Sputum culture and sensitivity identify the specific bacteria causing pneumonia and their antibiotic susceptibilities, ensuring targeted therapy. Inappropriate antibiotics risk treatment failure and resistance. Obtaining the culture before antibiotics prevents false-negative results, making this critical for effective treatment.

Choice C reason: A chest radiograph confirms pneumonia’s presence and extent but does not identify the causative organism or antibiotic sensitivity. It supports diagnosis but does not guide specific antibiotic therapy, making it less critical than sputum culture for ensuring appropriate treatment.

Choice D reason: A complete blood count with differential shows infection severity (e.g., elevated white cells) but does not identify specific bacteria or antibiotic sensitivity. It supports diagnosis but is secondary to sputum culture, which ensures targeted antibiotic selection for effective pneumonia treatment.

A. I will decrease the amount of fluids I drink each day. B. I will avoid foods high in sodium. C. I will weigh myself once a week on the same scale. D. I will call the physician’s office if swelling occurs.

Correct Answer is C

Explanation

Choice A reason: Decreasing fluid intake is appropriate for hypervolemia, as excess fluid exacerbates conditions like heart failure, causing edema and hypertension. Limiting fluids reduces fluid overload, preventing complications like pulmonary edema, indicating the client understands this aspect, requiring no further teaching on this point.

Choice B reason: Avoiding high-sodium foods is correct, as sodium retains water, worsening hypervolemia. Reducing sodium prevents fluid retention, lowering risks of edema and heart failure exacerbation, showing the client understands this self-management strategy, making further teaching unnecessary for this aspect of hypervolemia care.

Choice C reason: Weighing oneself weekly is inadequate for hypervolemia, as daily monitoring detects early fluid retention (2-3 pounds). Sudden weight gain signals worsening fluid overload, risking pulmonary edema. This statement indicates a need for further teaching on the importance of daily weights to manage hypervolemia effectively.

Choice D reason: Calling the physician for swelling is appropriate, as edema indicates fluid retention in hypervolemia. Prompt reporting allows early intervention to prevent complications like heart failure, showing the client understands this action, requiring no further teaching on reporting symptoms for timely medical management.

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A client has a sodium level of 121 mEq/L. What is the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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